A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
A.
Superficial palpation
B.
Auscultation
C.
Inspection
D.
Deep palpation
The correct answer and Explanation is :
To perform an abdominal assessment on a child, a nurse should follow a specific sequence to ensure an accurate and thorough examination. Here is the correct order:
- Inspection (C)
- Auscultation (B)
- Superficial palpation (A)
- Deep palpation (D)
Explanation:
- Inspection (C): This is the first step in the abdominal assessment process. The nurse visually inspects the child’s abdomen for any abnormalities, such as distension, asymmetry, or discoloration. Observation includes noting the shape of the abdomen, the presence of any visible masses, or unusual movements. Inspection also involves observing the child’s overall comfort and behavior, which can provide clues about their abdominal health.
- Auscultation (B): After inspection, the nurse should use a stethoscope to listen to the bowel sounds. This step is crucial because palpation and percussion can alter bowel sounds, potentially leading to inaccurate findings. Auscultation helps assess the presence, frequency, and quality of bowel sounds, which are important for evaluating gastrointestinal function.
- Superficial palpation (A): Next, the nurse performs superficial palpation. This involves gently pressing on the abdomen with the fingers to assess for tenderness, muscle tone, and any surface-level abnormalities. Superficial palpation helps to identify areas of pain or discomfort and provides information about the abdominal wall’s condition.
- Deep palpation (D): Finally, the nurse proceeds with deep palpation. This technique involves pressing more firmly to evaluate deeper structures and organs. It helps to identify any masses, enlarged organs, or unusual firmness within the abdomen. Deep palpation is conducted with care, especially in children, to avoid causing unnecessary discomfort.
Following this sequence ensures that the nurse conducts a comprehensive assessment while minimizing the risk of altering the findings due to earlier steps.